Mittermayr Markus, Streif Werner, Haas Thorsten, Fries Dietmar, Velik-Salchner Corinna, Klingler Anton, Oswald Elgar, Bach Christian, Schnapka-Koepf Mirjam, Innerhofer Petra
Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.
Anesth Analg. 2007 Oct;105(4):905-17, table of contents. doi: 10.1213/01.ane.0000280481.18570.27.
To explore whether disturbed fibrin polymerization is the main problem underlying dilutional coagulopathy and can be reversed by fibrinogen administration, we conducted a prospective study using modified thrombelastography (ROTEM).
Sixty-six orthopedic patients randomly received modified gelatin solution, hydroxyethyl starch 130/0.4, or exclusively Ringer lactate solution. ROTEM analysis was performed, concentrations of coagulation factors and markers of thrombin generation were measured. Fibrinogen concentrate (Hemocomplettan) was administered (30 mg/kg) when thrombelastographically measured fibrinogen polymerization was critically decreased.
The alpha angle, clot firmness, and fibrinogen polymerization (median [min to max]) significantly decreased in the patients receiving hydroxyethyl starch (area under the curve minus baseline (-5 [-9 to -2]), followed by gelatin solution (-3 [-8 to 0]), with the least reductions seen for Ringer lactate solution (-2 [- 4 to 1]) (colloids versus Ringer lactate P < 0.0001). Thirteen patients in the colloid groups but none in the Ringer lactate group needed fibrinogen concentrate to maintain borderline clot firmness. Activity of FVII, FVIII, FIX, and von Willebrand ristocetin activity decreased significantly with colloids. Thrombelastographically measured coagulation time, molecular markers of thrombin generation, and activity of all other coagulation factors were comparable in all groups.
Disturbance of fibrinogen/fibrin polymerization is the primary problem triggering dilutional coagulopathy during major orthopedic surgery. The magnitude of clot firmness reduction is determined by the type of fluid used, with hydroxyethyl starch showing the most pronounced effects. These undesirable effects of intravascular volume therapy can be reversed by increasing fibrinogen concentration by administering fibrinogen concentrate, even during continuing blood loss and intravascular volume replacement.
为探究纤维蛋白聚合紊乱是否是稀释性凝血病的主要潜在问题，以及是否可通过输注纤维蛋白原得到纠正，我们采用改良血栓弹力图（ROTEM）进行了一项前瞻性研究。
66例骨科患者随机接受改良明胶溶液、羟乙基淀粉130/0.4或单纯乳酸林格液。进行ROTEM分析，测定凝血因子浓度和凝血酶生成标志物。当血栓弹力图测定的纤维蛋白原聚合显著降低时，给予纤维蛋白原浓缩剂（Hemocomplettan，30mg/kg）。
接受羟乙基淀粉的患者，α角、血栓硬度和纤维蛋白原聚合（中位数[最小值至最大值]）显著降低（曲线下面积减去基线值（-5[-9至-2]），其次是明胶溶液组（-3[-8至0]），乳酸林格液组降低最少（-2[-4至1]）（胶体液与乳酸林格液相比，P<0.0001）。胶体液组有13例患者需要纤维蛋白原浓缩剂来维持临界血栓硬度，而乳酸林格液组无此情况。使用胶体液时，FVII、FVIII、FIX活性和血管性血友病因子瑞斯托霉素辅因子活性显著降低。血栓弹力图测定的凝血时间、凝血酶生成分子标志物以及所有其他凝血因子活性在所有组中相当。
纤维蛋白原/纤维蛋白聚合紊乱是大型骨科手术期间引发稀释性凝血病的主要问题。血栓硬度降低的程度取决于所用液体的类型，羟乙基淀粉的影响最为显著。即使在持续失血和进行血管内容量置换期间，通过给予纤维蛋白原浓缩剂提高纤维蛋白原浓度，可逆转血管内容量治疗的这些不良影响。
